Anesthesia Stat
A 4-month-old boy with a history of Pierre Robin sequence presents to the emergency department in respiratory distress secondary to bronchiolitis. The team makes the decision to intubate. Which physical exam feature found in this patient is most likely to lead to a difficult airway?
A. Distance of 6.5 cm between the mandible and thyroid prominence
B. Small Mandible
C. Small tongue
D. Wide palate
B. Small Mandible
A 14 y/o adolescent girl presents to the ED with a worsening swelling of the right side of her neck for the past week. On exam, she has a fluctuant mass noted at the angle of the mandible, anterior to the sternocleidomastoid muscle with mild tenderness to palpation, warmth, and a central pit with no active drainage. Which of the following is the next best step in management?
A. Admit for treatment with IV antibiotics
B. Incision and drainage of the mass in the ED
C. Obtain an ultrasound of the mass
D. Obtain a CT neck with IV contrast
C. Obtain an ultrasound of the mass
A 4-year-old boy with a known peanut allergy presents to the emergency department after ingesting a peanut-containing cookie at a birthday party. He vomited once and was brought in by his parents for further evaluation. On examination, his HR is 130 bpm, BP is 70/30 mm Hg, and SpO2 is 100% on room air. Which of the following is the best next step?
A. Intramuscular epinephrine
B. Intravenous antihistamine
C. Intravenous corticosteroid
D. Intravenous fluid
A. Intramuscular epinephrine
A 5-year-old boy presents to the emergency department with facial swelling. The swelling began < 30 minutes ago, only involving the lips. His vital signs are within normal limits for his age, and other than the lip swelling, his exam is unremarkable. Neither he nor his family members have ever had swelling like this. Which of the following is the best next step to care for this patient?
A. Endotracheal intubation
B. Intramuscular epinephrine
C. Oral diphenhydramine
D. Subcutaneous ecallantide
C. Oral diphenhydramine
A 15-month-old boy presents to the emergency department after a choking episode. His parents report that he had an episode of coughing and retching shortly after he was found with something shiny in his mouth. They state he has not had any drooling. Other than fussiness, his exam is unremarkable. His X-ray is shown above. Which of the following is the most appropriate next step to care for this patient?
A. Administer 0.5 mg of IV glucagon
B. Expectant management
C. Give 5 mL of oral honey
D. Use the foley catheter technique
C. Give 5 mL of oral honey
A 3-month-old boy presents to the emergency department after being ejected from a motor vehicle during a collision. The patient is cyanotic and unresponsive on arrival with an oxygen saturation of 82% and a HR of 140 bpm. The only obvious injuries are substantial facial injuries with full-thickness lacerations to the cheek and tongue, including an open mandibular and nasal bone fracture preventing effective bag-mask ventilation. You are unable to visualize the airway using direct laryngoscopy due to bleeding and loss of facial structure. The patient’s oxygen saturation drops to 62% and HR to 40 bpm. A laryngeal mask airway is ineffective. Which of the following is the most appropriate next step to treat this patient?
A. Cricothyrotomy
B. Nasopharyngeal airway
C. Oropharyngeal airway
D. Tracheostomy
C. Oropharyngeal airway
A 6y/o boy presents with new neck swelling after several days of cough and congestion. On exam, he is noted to have a tender, anterior midline mass with overlying warmth and erythema which moves with tongue protrusion. Which of the following is true regarding this diagnosis?
A. Definitive treatment is with surgical excision
B. Exam findings can include a thrill or bruit over the lesion
C. Infection is typically caused by Bartonella henselae
D. Initial treatment should include incision and drainage
A. Definitive treatment is with surgical excision
A 13-year-old boy presents to the emergency department with the above rash noted on his upper arms, thighs, abdomen, and back. The rash started only a few hours ago while outside exercising. The patient has had no known exposure to new foods, soaps, detergents, or animals. His parent gave him a dose of diphenhydramine, after which the patient immediately vomited. He appears uncomfortable from itching, but his vital signs are within normal limits for his age, and he has no wheezing on auscultation. He has persistent vomiting despite intravenous diphenhydramine, ondansetron, and promethazine. Which of the following is the most likely diagnosis?
A. Acute idiopathic urticaria
B. Anaphylaxis
C. Milaria
D. Serum sickness-like reaction
B. Anaphylaxis
A 2-year-old boy presents with an itchy rash and joint pain, which appeared suddenly this afternoon. His parent is concerned because he ate peanuts earlier this morning, although he has had them in the past without problems. He also developed a cough and rhinorrhea 2 days ago and is taking amoxicillin for an ear infection diagnosed 8 days ago. He has not had any vomiting or difficulty breathing. His temperature is 38.1°C (100.6°F), and his exam is remarkable for only the rash shown above. His fever and joint pain resolve quickly with acetaminophen. Which of the following is the most likely diagnosis?
A. Anaphylaxis
B. IgA vasculitis
C. Serum sickness-like reaction
D. Viral exanthem
C. Serum sickness-like reaction
A 3-year-old boy presents with stridor. His parent states that he was eating a grape and suddenly started choking. The patient has normal vital signs except for an increased respiratory rate. Physical examination reveals an anxious child who is able to speak but with stridor. Which of the following management steps is most likely indicated?
A. Back Blows
B. Emergent ENT consult
C. Heimlich maneuver with patient supine
D. Needle cricothyrotomy
B. Emergent ENT consult
A 4-year-old 20 kg boy presents to the emergency department with fever, cough, and difficulty breathing. He is toxic-appearing and unresponsive to attempts at IV placement. His temperature is 41.3°C, heart rate is 180 bpm, respiratory rate is 82/min, blood pressure is 64/30 mm Hg, and oxygen saturation is 71%. He has no breath sounds on the right, and his tachypnea is quiet and shallow. His capillary refill is 6 sec. You and your team push an IV fluid bolus and provide bag-mask ventilation while preparing for intubation. Which of the following is the most appropriate induction agent for this patient?
A. Etomidate 6 mg
B. Ketamine 30 mg
C. Midazolam 4 mg
D. Propofol 70 mg
B. Ketamine 30 mg
A 17-year-old vaccinated and otherwise healthy boy presents to your ED with right-sided anterior neck stiffness and pain. He had a sore throat 1 week ago and tested negative for Streptococcus. He does not report a headache or posterior neck pain. Vital signs show a temperature of 39.8°C, heart rate of 140 bpm, respiratory rate of 26/min, and blood pressure of 124/82 mm Hg. He is toxic appearing but alert and answering questions appropriately. He refuses to move his head to the right or flex his neck. He has moderate soft and mobile anterior cervical lymphadenopathy greater on the right and exquisite tenderness over his right anterior neck. His oropharynx shows mild erythema without uvular deviation or tonsillar hypertrophy. The Kernig sign is negative. Of the following, which is the most likely diagnosis?
A. Atlantoaxial rotary subluxation
B. Bacterial meningitis
C. Klippel-Feil syndrome
D. Septic thrombophlebitis
D. Septic thrombophlebitis
A 3-year-old boy is brought to the emergency department for a rash. It is widespread with edematous and erythematous papules and plaques on the entire body. An example of his rash is shown above. He has had no fevers, vomiting, or difficulty breathing. He has not had any recent medications, new foods, or exposures to new animals, soaps, detergents, or perfumes, and no recent travel. His vital signs are within normal limits for his age. Which of the following is the most appropriate initial treatment?
A. Cetirizine
B. Emollients
C. Epinephrine
D. Prednisone
A. Cetirizine
A 4-year-old girl with a history of immune thrombocytopenia presents with fever, fatigue, joint pain, and an itchy rash. Her vital signs are within normal limits, aside from a temperature of 100.4°F (38°C). Her parents report that she has been receiving rituximab infusions for the last month, with the last infusion occurring 4 days ago. She went to an urgent care earlier today and was placed on clindamycin, acetaminophen, and ibuprofen for suspected cellulitis. Your exam finds a diffuse, erythematous, urticarial rash and angioedema. Which of the following medications is the most likely cause of her symptoms?
A. Acetaminophen
B. Clindamycin
C. Ibuprofen
D. Rituximab
D. Rituximab
A 6-month-old girl presents to the emergency department after a choking and coughing episode while being fed a piece of an apple. Which of the following physical exam findings would be particularly concerning for a life-threatening airway obstruction in this patient?
A. Drooling
B. Focal wheezing
C. Persistent coughing
D. Unilateral diminished breath sounds
A. Drooling
A 3-month-old boy presents to the emergency department after being ejected from a motor vehicle during a collision. The patient is cyanotic and unresponsive on arrival with an oxygen saturation of 82% and a HR of 140 bpm. The only obvious injuries are substantial facial injuries with full-thickness lacerations to the cheek and tongue, including an open mandibular and nasal bone fracture preventing effective bag-mask ventilation. You are unable to visualize the airway using direct laryngoscopy due to bleeding and loss of facial structure. The patient’s oxygen saturation drops to 62% and HR to 40 bpm. A laryngeal mask airway is ineffective. Which of the following is the most appropriate next step to treat this patient?
A. Cricothyrotomy
B. Fiberoptic tracheoscopy
C. Indirect laryngoscopy
D. Percutaneous needle cricothyrotomy
D. Percutaneous needle cricothyrotomy
A father brings his 15 m.o daughter to the ED for evaluation of worsening painless swelling of her posterior neck after an episode of crying. On exam, she is noted to have a compressible, mobile mass posterior to the left sternocleidomastoid muscle which transilluminates. What is the most likely diagnosis?
A. Cystic hygroma
B. Infected branchial cleft cyst
C. Infected thyroglossal duct cyst
D. Lymphadenitis
A. Cystic hygroma
A 13-year-old girl presents with tongue swelling, wheezing, and difficulty breathing after being stung by a bee. What is the best initial treatment?
A. 0.3–0.5 mL intramuscular 1 mg/mL (1:1,000) solution of epinephrine
B. 0.3–0.5 mL intravenous 1 mg/mL (1:1,000) solution of epinephrine
C. 0.3–0.5 mL subcutaneous 0.1 mg/mL (1:10,000) solution of epinephrine
D. 10 mL intravenous 0.1 mg/mL (1:10,000) solution of epinephrine
A. 0.3–0.5 mL intramuscular 1 mg/mL (1:1,000) solution of epinephrine
An 8-year-old girl presents to the emergency department with facial swelling. She has asymmetric, nonpitting, non-gravity-dependent edema, as shown above. Which of the following history and exam findings most suggests this patient has C1 esterase inhibitor deficiency?
A. Expiratory wheezing on auscultation
B. Generalized skin flushing
C. Gradual onset over 24 hours
D. Hypotension
C. Gradual onset over 24 hours
A 2-year-old unvaccinated boy presents to the emergency department with concerns about respiratory distress. His parent reports that he awoke in his usual state of health and was playing alone in the playroom when she heard him have a coughing fit. Since that time, he has been choking and coughing, has inspiratory stridor, and developed significantly increased breathing work. What is the most likely etiology of his stridor?
A. Acute asthma exacerbation
B. Croup secondary to parainfluenza virus
C. Epiglottitis secondary to Hemophilus influenzae
D. Foreign body aspiration
D. Foreign body aspiration
A 2-year-old boy was hit in the mouth with a water balloon and developed sudden difficulty breathing. His parent called emergency medical services for rapid transport to your ED. En route, he became somnolent and is apneic on arrival. Using direct laryngoscopy, you are able to visualize but not remove the yellow balloon immediately below his glottis. A staff member is calling your difficult airway team, and the patient’s heart rate slows. What three pieces of equipment do you need to perform a needle cricothyrotomy on this patient?
A. 5 mL syringe, 3.0 mm endotracheal tube adapter, and 16 G over-the-needle catheter
B. 5 mL syringe, 3.0 mm endotracheal tube adapter, and 20 G over-the-needle catheter
C. 5 mL syringe, 5.0 mm endotracheal tube adapter, and 16 G over-the-needle catheter
D. 5 mL syringe, 5.0 mm endotracheal tube adapter, and 20 G over-the-needle catheter
A. 5 mL syringe, 3.0 mm endotracheal tube adapter, and 16 G over-the-needle catheter
A 7-year-old well-appearing boy presents to the emergency department with sudden-onset neck fullness and chest pain. You find moderate symmetric fullness in his neck anteriorly, and you feel a crunching sensation on palpation of the anterior neck as if his skin were like tissue paper. The above X-ray is obtained. Which of the following is the most common predisposing condition for this diagnosis?
A. Asthma
B. Diabetes
C. Recent airplane travel
D. Vomiting
A. Asthma
A 17-year-old girl presents with shortness of breath, rash, and nausea after an insect bite. Her vital signs are T 97.7°F (36.5°C), HR 128 bpm, BP 85/56 mm Hg, RR 28/min, and SpO2 93%. Exam reveals diffuse hives and posterior pharyngeal swelling. Which of the following should be immediately administered?
A. Epinephrine 1:1,000 (1 mg/mL) 0.3 mL IM
B. Epinephrine 1:1,000 (1 mg/mL) 0.3 mL IV
C. Epinephrine 1:10,000 (0.1 mg/mL) 0.3 mL IM
D. Epinephrine 1:10,000 (0.1 mg/mL) 10 mL IV
A. Epinephrine 1:1,000 (1 mg/mL) 0.3 mL IM
An 8-year-old boy presents to the emergency department with lip swelling. The swelling is asymmetric, profound, and involves the upper lips without involving the pharynx. Which of the following would suggest this patient’s symptoms will be prolonged?
A. The swelling occurs with abdominal pain
B. The swelling occurs with common cold symptoms
C. The swelling occurs with hives, itching, or bronchospasm
D. The swelling occurs with ibuprofen administration
A. The swelling occurs with abdominal pain
An 18-month-old boy presents to the emergency department unresponsive after eating a peanut. He was eating the peanut when he suddenly began choking and collapsed. The patient arrives after a short transport time, unsuccessful abdominal thrusts, and without intravenous access. He is pale and unresponsive and has an oxygen saturation of 76% with bag valve mask ventilation. He has intermittent spontaneous respirations and severe retractions. You hear no air movement on auscultation with respirations or positive pressure. The patient’s heart rate rapidly slows from 180 to 60 bpm. Which of the following is the most appropriate next step?
A. Direct laryngoscopy with Magill forceps
B. Epinephrine 0.3 mg intramuscular
C. Needle cricothyroidotomy
D. Rapid sequence intubation
A. Direct laryngoscopy with Magill forceps